Evaluating the impact of maternal health care policy on stillbirth and perinatal mortality in Ghana; a mixed method approach using two rounds of Ghana demographic and health survey data sets and qualitative design technique

Background Stillbirth and perinatal mortality issues continue to receive inadequate policy attention in Ghana despite government efforts maternal health care policy intervention over the years. The development has raised concerns as to whether Ghana can achieve the World Health Organization target of 12 per 1000 live births by the year 2030. Purpose In this study, we compared stillbirth and perinatal mortality between two groups of women who registered and benefitted from Ghana’s ‘free’ maternal health care policy and those who did not. We further explored the contextual factors of utilization of maternal health care under the ‘free’ policy to find explanation to the quantitative findings. Methods The study adopted a mixed method approach, first using two rounds of Ghana Demographic and Health Survey data sets, 2008 and 2014 as baseline and end line respectively. We constructed outcome variables of stillbirth and perinatal mortality from the under 5 mortality variables (n = 487). We then analyzed for association using multiple logistics regression and checked for sensitivity and over dispersion using Poisson and negative binomial regression models, while adjusting for confounding. We also conducted 23 in-depth interviews and 8 focus group discussions for doctors, midwives and pregnant women and analyzed the contents of the transcripts thematically with verbatim quotes. Results Stillbirth rate increased in 2014 by 2 per 1000 live births. On the other hand, perinatal mortality rate declined within the same period by 4 per 1000 live births. Newborns were 1.64 times more likely to be stillborn; aOR: 1.64; 95% [CI: 1.02, 2.65] and 2.04 times more likely to die before their 6th day of life; aOR: 2.04; 95% [CI: 1.28, 3.25] among the ‘free’ maternal health care policy group, compared to the no ‘free’ maternal health care policy group, and the differences were statistically significant, p< 0.041; p< 0.003, respectively. Routine medicines such as folic acid and multi-vitamins were intermittently in short supply forcing private purchase by pregnant women to augment their routine requirement. Also, pregnant women in labor took in local concoction as oxytocin, ostensibly to fast track the labor process and inadvertently leading to complications of uterine rapture thus, increasing the risk of stillbirths. Conclusion Even though perinatal mortality rate declined overall in 2014, the proportion of stillbirth and perinatal death is declining slowly despite the ‘free’ policy intervention. Shortage of medicine commodities, inadequate monitoring of labor process coupled with pregnant women intake of traditional herbs, perhaps explains the current rate of stillbirth and perinatal death.

The qualitative study found that, routine medicines such as folic acid and multivitamine were in intermittently in short supply forcing private purchase by pregnant women to augment their routine requirement. Also, the study found that pregnant women in labour took local concoction as oxytocin ostensibly to fast track the labour process and inadvertently causing complications of uterine rapture increasing the likelihood of stillbirths.

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Type text here Conclusion: Even though perinatal mortality rate decline overall between 2008 and 2014, the proportion of stillbirth and perinatal death is still on the rise, thus, the 'free' policy intervention has yet to translate to the desired decline in stillbirths since its inception in 2008. Shortage of medicine commodities, inadequate monitoring of labour process coupled with pregnant women intake of traditional herbs are probably some explanations to the current and perhaps influencing stillbirth outcomes.  The authors received no specific funding for this work.

Competing Interests
The authors have declared that no competing interest exist.

Introduction
Stillbirth and perinatal mortality are a critical healthcare index that has yet to receive adequate research and policy attention, particularly in developing countries (1)(2)(3). Stillbirth in particular presents economic and social effect to families particularly, the affected mother often leading to social withdrawal, loneliness and depression, affecting the psychosocial wellbeing of affected persons (4).
Globally, 2.6 million pregnancies end in stillbirths for one reason or the other despite improvement in access to care (5)(6)(7)(8). Presently, the data show that despite the introduction of access to care interventions in developing countries such as social health insurance, 98% of stillbirth are still accounted for by lower and middle income countries, particularly in south-east Asia and sub-Saharan Africa (9)(10)(11).
As at 2015, Nigeria recorded a stillbirth rate of 42 per 1000 live births, whereas developed countries like Japan and UK recorded an average of 2 per 1000 live births (12,13). About the same period Ghana recorded 28 per 1000 live births (14,15).
Generally, stillbirth is defined as a fetus with no sign of life prior to delivery or expulsion (16,17).
Technically, the WHO defines stillbirth as intrauterine death after conception. In practice however, gestational age of 20 to 28 weeks or a birth weight of 350 to 1000g is usually required in health law to determine stillbirth (16).
Access to maternal health care is proven to reduce stillbirth, and thus, the government of Ghana declared the 'free' registration of pregnant women to its national health insurance scheme in 2008 aimed at bridging the access gap to care usually induced by poverty (18,19). While the 'free' policy targeted access to care in particular, its broader intention was envisaged at tackling not just maternal mortality, but also to achieve a reduction in neonatal mortality by the provision of comprehensive pregnancy and newborn care during the perinatal period with the hope of meeting the then millennium development goal 4 and 5 (now sustainable development goal 3) (20-25).
The 'free' policy initiative received financial pledge from the then UK government to the tune of £42.5 million as a seed money. The policy has since survived a decade in its implementation and covered over 3 million beneficiaries since its inception in 2008 (26,27).
In spite of the intervention, stillbirth rates in Ghana have yet to drop substantially to measure up to desired targets if Ghana were to achieve the World Health Organization (WHO) goal of 12 per 1000 live births by the year 2030 (28,29). So far, studies on the 'free' policy impact have centered mainly on maternal health care utilization across districts and also, cross-country comparison of infant mortality in the West African sub-region (19,30,31).
In contrast, the 'free' maternal health policy impact on stillbirth perinatal mortality has yet to receive adequate attention relative to implementation of the 'free' maternal health care policy.
More so, while the data on skilled delivery improves following the 'free' maternal health care policy initiative, stillbirth still appears to be increasing even among facility deliveries (32,33).
Thus, in this paper, we analyse the outcomes of stillbirth and perinatal deaths among mothers in2008, when the policy had just started, compared to 2014 when the policy was fully rolled out.
The study examined the 'free' policy association with the outcomes of interest to see the likelihood stillbirth and perinatal death being recorded among mothers who benefited from the 'free' policy, compared to mothers who did not.
Even though tailored interventions have been shown to yield effect on reduction stillbirth, some other studies insist that reduced outcome in stillbirth are often dependent on local contest(34), hence, we finally explored the views of service providers and pregnant women as policy implementers and policy users respectively, to examine the context under which the 'free' policy thrives to aid policy review and brief.

Conceptual framework
We hypothesized that certain factors undermine the successful operationalization of the 'free' maternal health care policy in Ghana (Fig 1) and hinders the intention of the 'free' policy which was introduced to increase maternal health care utilization to bring about a decline in not just maternal mortality, but also stillbirth and perinatal mortality in the medium to long term.
The 'free' maternal health care policy is administered via the national health insurance scheme (NHIS) which in itself is bedeviled with funding constraints culminating in delays in payment of claims over the years (35,36). Consequently, it appears the existing challenges affect the effective management of accredited service provider facilities thereby threatening the credibility of the purchaser provider split concept (37).
On another level, the Ghanaian society presents itself as keeper of pregnant women with cultural demands that upset the effective implementation of the 'free' policy as well. These unintended practices seem to derail efforts of health care professionals and policy makers and hence, seem to frustrate their efforts of achieving reduced mortality outcomes of new born care.

Study design
Ghana implements the 'free' maternal health care policy via the National Health Insurance Scheme

Study setting
The quantitative analysis used Ghana Demography and Health Survey data sets, nationally representative, as data for the analysis. However, three districts each were considered from two regions of Ghana to explore the context within which the 'free' maternal health care is implemented relative to stillbirth and perinatal mortality. Both regions were selected from northern Ghana; the Upper East region and the Northern region (Fig 2).
The Upper East Region is one of the poorest regions of Ghana. It is located at the north-eastern corner of Ghana between longitude 0 0 and 1 0 West and latitude 10 0 30' N and 11 0 N. The region has a total land area of about 8,842sq km with Bolgatanga as its capital and an estimated population of a little over 1million (41,42). As at 2013, the region had a national health insurance enrollment rate of 6.3% of its total population with a considerably good number of midwives compared to other regions of Ghana (43). Three districts were selected from the UER for the primary data collection.
On the other hand, the Northern region is shared boundary to the Upper East Region, prior to 2018. As 2015, literacy rate was poor the Northern, less than 50% (44). The Northern region shares boundaries with the Republic of Togo to the East and the Savana Region to the south and the North-East region to the north. The region has a land mass stretching about 70,765.2km 2 with an estimated population of about 1.8m representing 9.6% of the total Ghanaian population. Three districts were also considered for the qualitative data from the Northern region.

Qualitative
Medical doctors, midwives and pregnant women were recruited from selected health care facilities across two region of Ghana for in-depth interviews (IDIs) and focus group discussions (FGDs). The regions were divided into three zones; from which one district each was selected using simple random sampling. A hospital each and two health centers per zone, were further selected as the final study sites from which study the participants were recruited purposively from the labour sections and the antenatal care units for the study. Pregnant women attending antenatal clinics in the selected facilities were also recruited conveniently for the focus group discussions.
The use of multiple sources of data (service provider and pregnant women) was to explore the idea of multiple realities (45).

Data collection and analysis
Tools and pretesting Interviews guides were developed and pre-tested among midwifery staff in a hospital which was not part of the selected study sites. We then revised the tools based on our observations. The Graduate Studies Committee of the University Ghana School of Public Health then approved of the tools and these were attached to the study protocol and received approval from Ghana Health Service Ethics Review Committee (letter attached) as tools for the in-depth interviews (IDIs) and focus group discussions (FGDs).
In-depth interviews were one-on-one for doctors and midwives using open ended interview questions. Each session lasted for about 1 hour and was audio taped. The focus groups ranged from 5 to 7 for the pregnant women participants who were attending antenatal care clinic at the selected health care facilities. We used fictional cases mainly at the FGDs to stimulate participation and aid discussion.

Inclusion criteria
The secondary data sets were those of the women data sets as contained

Exclusion criteria
Pregnant women receiving treatment for a medical condition were excluded from the study. Also, pregnant women less than 16 years were considered as minors under the 1992 constitution of the Republic of Ghana, and also excluded from the focus group discussion.

Quality control and trustworthiness
Weighting was applied to the GDHS data sets to cater for clustering and stratification across rural and urban areas of the then ten regions of Ghana, and analysis run using Taylor linearization technique for reduced standard error. For the qualitative study, the choice of purposive sampling was deliberate to achieve trustworthiness through the acquisition of the right information from service providers; doctors and midwives and pregnant women as policy users. To verify and triangulation data, we interviewed an expert Key Informant, a regional director of Ghana Health Service. This approach allowed us to validate the field data which was useful and catered for the idea of multiple sources of information as espoused by Creswell.

Statistical analysis
First, we estimated the overall ratios of stillbirth and perinatal mortality for the two rounds and also, the prevalence of stillbirth and perinatal mortality between the baseline and end line (2008 and 2014, respectively) to compare the outcomes, pre and post the 'free' policy intervention. We then identified confounding variables ( Table 2) using Rao-Scot chi square which were included in Poisson and multiple logistic regression models as covariates for the analysis of association.
Only variables which were statistically significant (p <0.05) in association with the outcome variables; stillbirth and perinatal mortality were included in the regression models. However, variable such as twin pregnancy (p= 0.4114), wealth index (p= 0.2408), and respondent region (p= 0.7535) were also included as confounding based on Mosley and Chen framework for child survival as modified in our conceptual framework even though these did not show statistically significant association with the outcome variables (46,47 The overall rate of stillbirth and perinatal mortality (Table 3)     Only 4 (8.9%) pregnant women participants were having children for the first time. Table 6 presents details composition of the qualitative study participants.  To the service providers, macerated stillbirths were being reported more, which suggest that babies die in utiro before they arrive at the facility. Service providers were also of the view that pregnant women reported late to health care facilities, sometimes to avoid procedures they appear uncomfortable with. Service providers also observed a culture of little or no attention to stillbirth issues. Public or media lack of attention on stillbirth was cited as a principal reason compared to maternal mortality. On the other hand, pregnant women midwives' snobbish attitude to them during labour, as a contributory factor to the rising stillbirths. The following quotes explains further; "We don't pay attention to stillbirth the way we do for maternal deaths. One mother will die and the whole hospital will here. I don't even know the stillbirths in the labour ward. They don't tell me…unless we are reporting. But when there is maternal mortality, eeeiii!" (Doctor3, IDI, UER) The views expressed by the medical doctors appear to be in consonance with a rather unethical practice exhibited by midwives which caught the attention of the pregnant women. The focus group discussion brought out that midwives hardly respond to the urgent calls of pregnant women in labour. Even though the reasons for their non-response was beyond the scope of this study, the descriptions during the focus group discussion suggest an underlying challenge that explains the poor outcomes of stillbirths. The pregnant women participants had these to say; "…Sometimes you can be crying and they won't mind you. Use of local herbs for 'rapid' uterine contraction Another interesting phenomenon that emerged from the IDIs was the use of local herbs for uterine contraction among pregnant women in labour. 'Kaligutiem' is a Dagbani (a Ghanaian language) term referring to herbal potion used by pregnant women to speed uterine contractions in labour, essentially acting as oxytocin. Unspecified doses of kaligutiem is given to some pregnant women from the study site hospital often by their mother in-laws and at the blind side of the health care professionals, to 'aid' the labour process.
The midwives account suggests that the potency of the locally produced oxytocin contributes to adverse events such as excessive contractions often leading to uterine rapture. Specific communities are notorious for the use of the local herb and mother in-laws are said to be the givers of this 'medicine' to quicken the labour process. Midwives and pregnant women give their account as follows; "They also take, '

Discussion
Generally, the study results across the independent covariates improved over time between 2008 and 2014 showing statistically significant differences between the GDHS data of the two rounds, particularly in the weighted characteristics. Similarly, there is a corresponding increase in nominal values among the outcomes variables; stillbirth and perinatal mortality. Population growth is one possible explanation, however, the introduction of the 'free' maternal health care policy was also key to these improvements (48)(49)(50).
In other related studies, maternal health care utilization improved drastically following the introduction of the 'free' policy, hence showing some congruence with the current study (30,48,51). Also consistent with result of the analysis is the rising numbers of stillbirth among health facility delivery. The service providers disclosed this as yet a concern during the in-depth interview and focus group discussions as concern which was common despite the implementation of the 'free' policy. On the other hand, the slight improvement in perinatal mortality may be due to the increase access to care and immunization in 2014 compared to 2008. Perinatal mortality is technically an epidemiological concept that includes stillbirth and therefore, a reasonable expectation for us was that as one declines, the other should also be declining as well (16,38,52).
Service providers noted in the IDIs that medicines were intermittently in short supply as pregnant women are often told to purchase some for themselves from private chemical shops and this could perhaps affect late pregnancy outcomes. For example, folic Acid, and ferrous sulphate (iron tablets) are routine drugs served at antenatal clinics as supplements to prevent anemia in pregnant women and these also aid in combating stillbirth (40,53).
In earlier studies, Mensah and others observed that 65% of pregnant women in rural Ghana take some form of antibiotics in addition to the routine medicines (54). With this, two possible scenarios could arise from the contextual factors. First, the risk of taking fake drug from the open market increased, and secondly, there is the likelihood of pregnant women not completing their required dose if they cannot afford the medicines from the market. Studies have shown that folic acid intake during pregnancy is associated with reduced stillbirth (55).
Another key finding from the qualitative analysis which may offer explanation to the rising stillbirth was the lack of ultra sound sonographers in most of the hospitals, particularly in the Upper East Region. All three hospitals studied in the Upper East region had no single sonographer to view and interprete ultrasound scan to aid the work of doctors and midwives. This led to a wide patronage of private ultra sound scans services to aid obstetric diagnosis.
Even though maternal health care utilization has increased, and perhaps a rise in record keeping, but this is against a background of diagnostic difficulties effectively relaying what Roos et. al., (2016) argues as contributory factors to undesirable outcomes of late pregnancy outcomes (6).
The ability of the service to accurately diagnose an obstetric condition is a functional quality issue and perhaps, hardly achieved in the current structure of services under the 'free' maternal health care policy (56,57).
Interestingly, stillbirth rate improved considerably in the Northern region in comparison to the Upper East region, despite the low coverage of facility delivery utilization in the Northern region.
The disparity in outcomes of stillbirth between the Upper East and Northern regions appear to suggest that some the underlying context factors may provide explanation to outcomes.
The use of delivery partograph was more of a problem in the Upper East region as one of the respondents puts it, "in the one hospital in the Upper East region, the use of partograph was 0 out of 100". The analysis of association shows that stillbirth was more likely to be recorded among the 'free' maternal health care policy group compared to the no 'free' maternal health care policy, which is consistent with the worsening indices as reflected in the rates.
Several factors affect stillbirth and perinatal mortality within the health system which in turn is affected by quality of care dimensions (58). Infection, anemia, preterm delivery and low birth weight are some of the associated factors of stillbirth and these, perhaps are inadequately tackled despite the upsurge of antenatal care uptake and facility level delivery utilization (15,59,60).
Perceived lack of care and attention was espoused by the pregnant women during the focus group discussion. The effect of this is that pregnant women may loss trust in facility level delivery and even turn up late and in complicated state, thus affecting care quality and outcomes (6,61).
The quality of care element is also manifested in the inadequate use of delivery partograph as elicited from the in-depth interviews (62,63). Earlier studies have explored reasons associated with limited or the complete lack of use of delivery partograph citing; inadequate staffing, lack of motivation and the complex nature of delivery partograph (20,64). This current study suggest that midwives have the tendency of not using the delivery partograph and this may be contributing to the increasing figures of stillbirth.
The findings also show that some pregnant women in the study site hospitals resort to local concoction known as kaligutiem to speed up contraction in labour, unaware of its adverse effect on the unborn child. It is not clear what could possibly be the motivation for pregnant women to want to hastened their labour process, nevertheless, the practice demonstrates some lack of confidence in the health care system's ability to conduct safe delivery of their babies.
While further studies may be required to establish any association between the use of kaligutiem and stillbirth outcomes, the account of midwives suggest that pregnant women who take to the local potion are at risk of uterine rapture due to the strong contractions experienced by the users.

Strength and Limitation
This is the first study to compare stillbirth and perinatal mortality outcome following the implementation of the Ghana's 'free' maternal health care policy in 2008. Our definition of stillbirth included born dead of dying within 24 hours after birth. This was necessary to widening the scope and increased the sample size for a much robust estimation.
One other strength of this study was the study use large data sets from Ghana Demographic and Health Survey which is based on multiple cross sectional survey with standardized questionnaire and nationally representative for public health policy evaluation. Another strength of this study was its mix method approach of evaluating not just the mortality outcomes, but also health system challenges which explained the contextual factors affecting the 'free' maternal health care policy operations and outcomes of late pregnancy. Perhaps the findings of this current study will serve to guide public health policy decisions on stillbirth and perinatal mortality.
In spite of the strengths, the quantitative analysis was based on association using regression models. This is considered a less robust method of determining impact of a policy intervention compared to a quasi-experimental design. Also, the selected regions for the qualitative design were both from northern Ghana, based on the analysis of stillbirth outcomes, thus, limiting the perspective of the pregnant women and service providers relative to the 'free' maternal health care policy.

Conclusion
While the overall perinatal mortality rate declined in 2014, stillbirth rate is still a concern under the current circumstance, thus, suggesting that the 'free' policy implementation is yet to translate meaningfully into reduction in stillbirth outcome. Of a major concern also, is the possibility that expectant mothers are at risk of not completing their required doses of folic acid or iron supplement and probably exposed to sub-standard medicine from the open market due to the intermittent facility level shortages of medicines consumable.
Essentially, access to care policy is not enough in driving the indices of newborn mortality towards desired outcomes, a holistic health system approach which ensures the availability of good quality medicine commodities and well trained human resources, including ultra-sound sonographers are critical to achieving set goals and targets.
Perhaps, the Ministry of Health and Ghana Health Service could adopt responsive approach to maternal health care services in Ghana and this probably, should go beyond bridging financial access gap to ensuring that medicine commodities, health technologies for diagnosis and adequately trained man power are available to support a responsive health system.
1 Figure 1: Moderating factors of stillbirth and perinatal mortality in a multifaceted relationship